Can San Francisco Become the First AIDS-Free City?

The city that was once the deadly AIDS epicenter of the world is now striving to be AIDS-free. What does that mean, and why is San Francisco poised to achieve this goal the way no other American city could?



San Francisco’s progressiveness can’t disguise a number of systemic flaws. Many of these aren’t unique to the city but are byproducts of America’s ramshackle economy, marked by income inequality, housing shortages, and unemployment. Michael Scarce, an activist and medical sociologist who has written two books about sexual politics, argues that these are the real blockades in San Francisco’s quest for a cure. “If you could choose one city that would be the first to become AIDS-free it could very well be San Francisco,” he says, “and yet all of the comorbidities and socioeconomic factors that intersect with HIV would need to be eliminated, if we’re going to truly be AIDS-free. I don’t know of that ever happening in the history of Western civilization.” High on the checklist of hurdles are poverty, substance abuse, and homelessness. “We can provide testing and treatment all we want,” Scarce tells me, “but if people at risk aren’t inspired and motivated to have lives worth living we can’t convince them to take advantage of something that might save their lives.”

Scarce has the bemused but edgy tone of someone who has made it out of the woods. “I’m not interested in body counts anymore,” he says, alluding to his own history of AIDS, drug addiction, and homelessness. Even now, he works two part-time jobs unrelated to his field and is trying to land a steady research gig. Three months ago he was served an eviction notice. He is burned out by PR buzzwords. “How are you going to save me if you don’t even know me or what my life is like? How are you going to help me get well? I’m not sure that I want to be saved. I just want a chance to save myself, and that’s a big difference.”

When asked what his ideal outreach model looks like, he replies that he’d like to see policy makers live a day in the life of someone with AIDS. Short of that, he’ll settle for more peer-based programs that actually administer to people with AIDS. In 2010, Scarce was interviewed by a French organization called the Warning. He used the opportunity to lambast the lack of transparency and general malaise among HIV/AIDS organizations and lobbied for the creation of a national watchdog agency. “In terms of fund- ing, Crisis = Money. Disease = Money. Risk = Money. The more AIDS organizations can portray their communities as unhealthy, sick, and high risk, the more they are rewarded financially and politically,” he said in the interview.

This is as good a time as any to point out that according to Charity Watch’s 2013 ratings guide, the San Francisco AIDS Foundation scores a C for how much it spends on programs and how much fundraising is required to raise $100. The foundation has the lowest grade of the eight AIDS organizations that are measured. There is also the matter of Neil Giuliano’s salary: $270,000 in 2012. The executive team, which in 2012 included seven members, earned a combined income of more than $1.3 million. The salaries are modest in comparison to some other nonprofits, but could they hint at a larger disconnect between organization heads and those they’d help? “When you talk about a 25% reduction in new infections, I start to zone out,” says Scarce. “A year from now I’m more worried about Am I going to have an apartment?”

In 2013, San Francisco’s housing market became the most expensive in the nation, with a median rent of $3,414. There was an 8% rent spike during a single quarter. Anxiety is palpable among long-time residents, especially since the past three years have also seen a 170% hike in Ellis Act evictions, which give retiring landlords carte blanche to evict their tenants. Gallons of ink and acres of bandwidth have gone into dissecting the city’s run- away gentrification, but little has been said about what it portends for San Francisco’s HIV/AIDS community.

Scarce sees the city’s elitism as just another reason he’ll fall through the cracks. “The city is still really behind wrapping its mind around homelessness,” he says. “When you don’t have a home, how are you supposed to get clean? How are you supposed to take your meds on a regular basis? How are you supposed to see your provider? And do you even want to do any of those things at that point?”

San Francisco is now in the uncomfortable position of having a cure within reach while being unable to offer it to many of the people who made it possible. It’s a bittersweet proposition. It’s also one that implicates front-line workers—nurses, benefits counselors, treatment advocates, case managers—who are often the lowest paid and most overworked. Scarce singles out Ellen at the San Francisco AIDS Foundation for special commendation: “God, I don’t know if I’d be here if it weren’t for her. She helped me and so many people I know in ways that are just mind-boggling. But you’re not interviewing Ellen. That’s not a criticism of you, it’s just the system.”

But should it be a criticism of anyone who presumes to talk about HIV/AIDS policy without first understanding the lives of people in the trenches? Politicians, CEOS, scientists, and researchers are all essential to orchestrating effective care, but their priorities, however well-intentioned, are generally light years away from those of people in the community. The story of HIV/AIDS is one that began on the street, and will hopefully end there as well. Whether a cure is discovered in San Francisco or some other charmed place, a happy ending is where the real demands of salvation must begin. “Personally,” says Scarce, “I would not want to be in San Francisco to hear champagne corks popping all over the city when seroconversions end and I’m living with AIDS on the street.”


CORRECTION: The print version of this article and the previously posted online version erroneously reported that Timothy Ray Brown, the "Berlin" patient, had relapsed from his functional cure of HIV. The Advocate regrets the error.